Jong-Shyong Chen

Assessment of serum and bile levels of CA19-9 and CA125 in cholangitis and bile duct carcinoma

In this study, CA19‐9 and CA125 in serum and bile were measured to evaluate their diagnostic value in cholangitis and bile duct carcinoma. Patients were classified into three groups: group A, the control group, had cholelithiasis without infection (n= 23), group B had acute cholangitis (n= 25) and group C had bile duct carcinoma without bacterial infection (n= 18). All patients had undergone surgery, and bile and serum of the patients were measured for the two tumour markers by radio‐immunoassay. The positivity rate for serum CA19‐9 was 4.4% in the control group, 28.0% in group B and 61.1% in group C. The positivity rates for serum CA125 in groups control, B and C were 0%, 4% and 27.78% respectively. The diagnostic accuracy for bile duct carcinoma was 67.4% for both CA19‐9 or CA125. The concentration of CA19‐9 in bile was more than 1200 ng/mL in 72% of patients with acute cholangitis, in 61.1% of all patients with bile duct carcinoma and 0% in the control group. The frequency of concentrations of CA125 in bile greater than 200 ng/mL was 38.89% in bile duct carcinoma and none was observed in the control or acute cholangitis groups. In conclusion, the concentration of CA19‐9 was increased not only by the tumour itself, but also by infection. In the diagnosis of bile duct carcinomas, the sensitivity of CA125 was low but its specificity was very high.

Long-Term Results of One Hundred and Seven Hepatic Resections for Intrahepatic Stones

During 11 years, 107 of 586 patients (18.3%) with intrahepatic stones underwent hepatic resection to remove intrahepatic stones at Kaohsiung Medical College Hospital. Guided by the location of the int

Hypertriglyceridemia-associated Acute Pancreatitis with Chylous Ascites in Pregnancy

Both cholesterol and triglyceride levels in serum increase progressively during pregnancy. Hypertriglyceridemia is a well-recognized cause of acute pancreatitis, while pancreatitis-associated chylous ascites has rarely been reported. We report a 28-year-old female with coexistence of hypertriglyceridemia, acute pancreatitis, and chylous ascites during pregnancy. After emergency cesarean section, she was treated with nil per os, intravenous hydration, antibiotics, and analgesics as required. Due to the development of positive peritonitis 5 days later, an exploratory laparotomy was performed. Surgical interventions included pancreatic necrosectomy, right hemicolectomy and ileostomy, cholecystostomy, gastrostomy, and feeding jejunostomy. Postoperative treatment included antibiotics, total parenteral nutrition, and then low-fat diet with medium-chain triglyceride supplementation. She was discharged on the 43rd day after surgery and was free of symptoms during 6 months of follow-up. Ileocolostomy was performed 6 months after discharge. Fasting lipid profile should be regularly monitored during pregnancy due to the association of hypertriglyceridemia with development of acute pancreatitis in the mother.

Percutaneous post-operative choledochofiberscopic lithotripsy for residual biliary stones

SummaryA total of 5,116 post-operative percutaneous choledochofiberscopy (POC) sessions were performed on 739 patients with residual bile duct stones between 1980 and 1988. These residual stones were detected and removed by choledochoscopy. The success rate of non-surgical stone removal using POC was 100% for residual common duct stones and required 414 treatment sessions in this group of 168 patients. The success rate was 92.2% (525/569) for patients with residual intrahepatic stones; in this group a total of 4,694 treatment sessions were needed. Two patients with residual cystic duct stones were also successfully treated with POC. The distribution of residual intrahepatic stones was as follows: 166 (29.2%) in the right hepatic duct, 255 (44.8%) in the left hepatic duct and 148 (26.0%) in both hepatic ducts. Complications after POC were minimal and subsided after conservative treatment except in 2 patients. One patient had hemobilia and another a large subphrenic abscess, which required surgical drainage. Choledochofiberscopic electrohydraulic shockwave lithotripsy was effective treatment for large stones and was well tolerated. Residual stones in Oriental gall-stone disease are not preventable, and we believe that POC should be the first choice for these patients. Many of the problems associated with residual stones can be overcome by this method and good results achieved.

Solid and Cystic Tumor of the Pancreas - Three Cases Report

Solid and cystic tumor of the pancreas is a rare, low-grade malignant tumor that predominantly occurs in young women. Clinically, the patients are often asymptomatic and are usually found incidentally due to other diseases. The pre-operative diagnosis is difficult due to the similarity to other cystic pancreatic lesions (such as serous adenoma, mucinous cystadenoma and endocrinologically inactive islet cell tumor), or inflammatory changes (such as pancreatic pseudocyst). This tumor has a slow growth, usually does not have metastases and has a favorable prognosis. Complete removal is the treatment of choice for the tumors arising anywhere in the pancreas. We collected specimens of pancreatic tumors that were kept at Kaohsiung Medical University Hospital (KMUH) in the past 11 years. Three cases varying in clinical course were found. The first is a case of a middle aged woman with a slow growing tumor who had a misdiagnosis of pseudocyst eight years ago. The second is a case of a young woman that showed no symptoms, while the third case was also a young woman diagnosed with a huge tumor with portal vein and inferior vessel encasement. We review some articles to revise the study of this disease in order to make the correct diagnosis before proceeding with the operation, and to provide proper treatment.

A Study of Cea, Ca 19-9 and Ca 125 in Biliary Tract Diseases

Sixty-six patients were classified into three groups; control group A was (n = 24), group B those with hepatolithiasis (n = 24) and group C those with the bile duct carcinoma (n = 18). All patients had accepted operation and the patients bile and serum were send for determination with radioimmuno assay. The positive rate of serum CEA were 4.17%, 37.5% and 66.67% for the control, hepatolithiasis and bile duct carcinoma groups respectively. The positive rate of serum CA 19-9 were 8.33%, 25% and 61.11% for the control, hepatolithiasis and bile duct carcinoma respectively. The positive rate of serum CA 125 were 5%, 0% and 31.25% for control, hepatolithiasis and bile duct carcinoma groups respectively. The sensitivity level of serum CEA, CA 19-9 and CA 125 for the bile duct carcinoma group was 66.67%, 61.11% and 31.25% respectively. The diagnostic accuracy for bile duct carcinoma with regard to bile CEA was 94.44% but the accuracy ratio was only 45.24%. The bile concentration of CA 19-9 level of more than 1200 ng/ml were 75% and 61.11% for the hepatolithiasis and bile duct carcinoma group and none in control group. The bile concentration of CA 125 more than 200 ng/ml was 43.75% in the bile duct carcinoma and none in control or hepatolithiasis group. Finally, the concentration of CA 19-9 will be effected not only by tumor itself but also by severe infection in the hepatolithiasis patients. The sensitivity of CA 125 was low but accuracy was high for the diagnosis of the bile duct carcinoma.

Changes of insulin and somatostatin and their relationship to liver regeneration in experimental obstructive jaundice.

The liver is a parenchymal organ that has a substantial capacity to regenerate after damage. Obstructive jaundice is a common surgical disease and potentially risky. A successful outcome of operations depends upon the hepatic regeneration reserve. Insulin is one of factors responsible for hepatotrophic regeneration and somatostatin has a reversal suppressive action. Experimental obstructive jaundice was introduced and relieved. In addition, serum insulin and somatostatin concentrations were measured. We used immuno-histochemical study of pancreatic tissue by immunogold to express the tissue relative insulin and somatostatin concentrations. Nucleolar organizer regions (NORs) were used to predict the nucleolar activity of liver cells. In our studies, we observed the serum concentrations of insulin and somatostatin were similar to the relative tissue concentration in pancreatic tissues. The relative tissue gold-particle score of insulin in group A (rats with common bile duct tied), was CONT: T4: T7: T14 = 100%: 90.5%: 68.3%: 46.2%; of somatostatin was 100%: 120%: 118.2%: 115.5% respectively. In group B (common bile duct tied for 4 days then relieved), the gold-particle score of insulin was T4: T4R4: T4R7: T4R14 = 90.5%: 62.8%: 72.2%: 95.4%; of somatostatin was 120.2%: 114.3%: 108.1%: 106.2% respectively. In group C (common bile duct tied for 7 days then relieved), the gold-particle score of insulin was T7: T7R4: T7R7: T7R14 = 68.3%: 53.3%: 73.5%; of somatostain was 118.2%: 109.4%: 104.6%: 102.1% respectively. The mean numbers of AgNORs in group A revealed CONT: T4: T7: T14 = 2.24 +/- 0.24: 3.02 +/- 0.96: 3.26 +/- 1.02:3.08 +/- 0.84, group B was T4: T4R4: T4R7: T4R14 = 3.02 +/- 0.96: 3.03 +/- 0.73: 3.36 +/- 1.12: 3.72 +/- 1.46, and group C showed T7: T7R4:T7R7: T7R14 = 3.26 +/- 1.02: 3.26 +/- 0.84: 3.31 +/- 1.24: 3.54 +/- 1.24. In conclusion, our studies suggested: (1) liver regeneration appeared promptly after obstructive jaundice developed, but prolonged cholestasis inhibited this process. (2) Insulin levels gradually fell during the process of obstructive jaundice. Those levels elevated when cholestasis was improved. Nevertheless, both insulin and hepatic regeneration power could not reflect the initial improvement of cholestasis simultaneously. It took a longer time for the improvement of cholestasis and the recovery of the liver function. (3) Patho-physiologically, somatostatin had a weak influence on hepatic regeneration during obstructive jaundice. (4) Our studies provided clues that early biliary drainage might improve hepatic regeneration capacity. Supplement of insulin during the obstructive jaundice might be helpful for the improvement of hepatic regeneration power.

Laparoscopic Fenestration for Giant Liver Cyst

Laparoscopic fenestration for treatment of the non-parasitic cyst of the liver has been rarely reported, but sporadic cases appeared elsewhere in the literature. Here we report four cases with symptomatic giant nonparasitic liver cysts which were treated by a laparoscopic fenestration procedure that allowed the successful removal of the cyst dome. Before starting to excise -the wall of the cyst, laparoscopic-qulded needle aspiration of the cyst fluid was done first in order to clean the visual field for laparoscopic intervention where possible. The cyst wall was usually slighty transparent and somewhat smooth in the external and internal surface of the cysts. It was necessary to lysis the omental adhesion sometime before starting to remove the dome of the cyst. The cyst wall of the exposed part could be removed first with heat-probe Instrument through laparoscopy. Those patients were discharged and revealed an uneventlul postoperative course in three cases but in one case we had to convert to the traditional laparostomy to perform resection of the multiple cystic lesions. Post-operative echo- graphic study showed that the giant cyst had collapsed. Therefore, we believe laparoscopic fenestration for the liver cyst is simple and effective, If the patient is a candidate who requires operation to remove the dome of the giant cyst.

Use of Ceftazidime in Hepatobiliary Surgery

Patients undergoing hepato-biliary surgery pose both diagnostic and therapeutic challenges. Such operations are commonly seen in Asian countries and especially in the Southern parts of Taiwan. Biliary pathogens are usually noticed when the disease coexists with gallstones. Bile stasis with bacterial infection predisposing to longstanding intermittent obstructive jaundice, cholangitis, liver abscess and septicemia results in high morbidity and mortality. Treatment is generally initiated with broad-spectrum antibiotics before operative intervention and culture results become available. The usual therapeutic regimen incudes beta-lactam agents with or without aminoglycoside. A clinical efficacy study was conducted using a single agent, ceftazidime, to treat twenty adults who underwent hepato-biliary surgery. Fiteen cases received ceftazidime as a therapeutic agent and five prophylactic ally. Thirteen of these patients showed clinical improvement with ceftazidime therapy and pathogens were eradicated in nine; the remaining six had aerobic Gram positive and anaerobic Gram negative bacteria presented;P. aeruginosa(1), E coli (1), Klebsiella oxytoca (1), Streptococcus faecalis (1) and Bacteroid fragilis (3). The prophylactive group showed no signs of infections following single dose pre-and post-operative boost injections of ceftazidime. Ceftazidime appears to be a useful agent in the treatment of patients undergoing hepato-biliary surgery, and especially those with Gram negative aerobic bacteria infections.

Hereditary hemorrhagic telangiectasia presenting as portal hypertension

Hereditary hemorrhagic telangiectasia (HHT), also known as OslereWebereRendu syndrome, is a rare genetic vascular disorder characterized by widespread telangiectases that may involve the skin, mucous membranes of the nasopharynx, lung, brain, liver, and urinary and gastrointestinal tracts [1]. We report here the case of a 25-year-old female who presented to the emergency department with complaints of progressive abdominal distension, tarry stool, and hematemesis. Laboratory examination showed the following: white blood cell count, 11,300 cells/uL; hemoglobin, 95 g/ L; platelet count, 187 1000 cells/uL; sodium, 131 mmol/L; potassium, 2.9 mmol/L; C-reactive protein, 59.3 mg/dL; and albumin, 26.2 g/L. Liver and renal function tests were normal. Esophagogastroduodenoscopy revealed multiple esophageal varices with bleeding. Abdominal computed tomography showed multiple hepatic arteriovenous malformations. Angiography disclosed multiple instances of huge, complicated right hepatic lobe arterioportal shunting and left lumbar vascular malformations (Fig. 1). Owing to a presumptive clinical diagnosis of HHT, we performed